How is postprandial (after meal) plasma glucose excursion managed in patients with diabetes?

From the Guidelines

Postprandial plasma glucose excursion in diabetic patients is best managed through a combination of medication timing, dietary modifications, and activity, with a target peak postprandial capillary plasma glucose of 180 mg/dl (10.0 mmol/l) as recommended by the 2011 standards of medical care in diabetes 1. To achieve this target, several strategies can be employed:

• Fast-acting insulin analogs like lispro, aspart, or glulisine should be administered 15 minutes before meals, with dosing based on carbohydrate counting (typically 1 unit per 10-15g of carbohydrates, adjusted for individual insulin sensitivity) 1.
• Non-insulin options include GLP-1 receptor agonists (like semaglutide or dulaglutide), DPP-4 inhibitors (sitagliptin, linagliptin), and alpha-glucosidase inhibitors (acarbose 50-100mg with meals) 1.
• Meal composition should emphasize low glycemic index foods, adequate fiber (25-30g daily), and distributing carbohydrates evenly throughout the day.
• Taking a 10-15 minute walk after meals can significantly reduce glucose spikes by increasing glucose uptake in muscle tissue. When basal insulin has been titrated to appropriate fasting blood glucose levels but the HbA1c level remains above target, combination injectable therapy should be considered to reduce postprandial glucose excursions, with options including a GLP-1 receptor agonist or prandial insulin 1. It is essential to individualize goals based on duration of diabetes, age/life expectancy, comorbid conditions, known CVD or advanced microvascular complications, hypoglycemia unawareness, and individual patient considerations, as outlined in the 2011 standards of medical care in diabetes 1.

From the FDA Drug Label

Repaglinide tablets therapy resulted in dose-proportional glucose lowering over the full dose range. Plasma insulin levels increased after meals and reverted toward baseline before the next meal. FPG and 2-hour post-prandial glucose (PPG) increased in patients receiving placebo and decreased in patients treated with repaglinide Differences between the repaglinide- and placebo-treated groups were -61 mg/dL (FPG) and -104 mg/dL (PPG)

The management of postprandial plasma glucose excursion in patients with diabetes using repaglinide involves dose-proportional glucose lowering. Repaglinide increases plasma insulin levels after meals, which helps to lower post-prandial glucose levels. The goal is to achieve a decrease in 2-hour post-prandial glucose (PPG) levels, as seen in the study where repaglinide-treated patients had a decrease of -104 mg/dL in PPG levels compared to placebo-treated patients 2.

• Key points:
  • Repaglinide lowers blood glucose levels by stimulating insulin release
  • Plasma insulin levels increase after meals and revert to baseline before the next meal
  • Repaglinide decreases 2-hour post-prandial glucose (PPG) levels
  • Dose-proportional glucose lowering is achieved with repaglinide therapy 2

From the Research

Postprandial Plasma Glucose Excursion Management

Postprandial plasma glucose excursion refers to the increase in blood glucose levels after a meal. Managing this excursion is crucial in patients with diabetes to prevent complications.

• Medications: Meglitinide analogues, such as repaglinide and nateglinide, are effective in reducing postprandial hyperglycaemia by stimulating insulin release 3. Sulfonylureas and meglitinides also stimulate insulin secretion, while metformin reduces insulin resistance 4.
• Lifestyle Modifications: Diet, physical activity, and sleep play a significant role in controlling postprandial glucose responses. Consuming less refined grains and more protein-rich foods, engaging in light-intensity physical activity, and having a longer sleep duration are associated with lower postprandial glucose levels 5.
• Combination Therapy: The majority of patients with type 2 diabetes require multiple therapies to attain target glycemic levels 6. Combination therapy, including diet, sulfonylurea, metformin, or insulin, can improve glycemic control.
• Physical Activity: Postprandial light physical activity, such as light bicycling, can blunt the blood glucose increase after a meal 7. This acute blood glucose reducing effect is similar to that obtained by hypoglycemic drugs.

Key Findings

• Meglitinide analogues are effective in reducing postprandial hyperglycaemia 3.
• Lifestyle modifications, including diet and physical activity, can control postprandial glucose responses 5.
• Combination therapy is often necessary to attain target glycemic levels 6.
• Postprandial light physical activity can reduce blood glucose increase after a meal 7.